Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

Free vaccines are available to children who are uninsured or qualify for public insurance.

But many states can’t afford to help children with inadequate private insurance that doesn’t cover new, expensive shots and even some older shots, the study found. That puts more than a million children at risk, researchers said.

Illinois, for example, doesn’t provide vaccines against chickenpox, pneumonia, hepatitis A, human papillomavirus and rotavirus to children with insufficient private insurance. Parents would have to pay $400 out of pocket for those vaccines.

“Health insurance plans are not necessarily keeping up with the new vaccines, posing significant ethical dilemmas to public health clinics,” said the study’s lead author Dr. Grace Lee of Harvard Medical School.

The study of the nation’s patchwork system of paying for immunizations appears in Wednesday’s Journal of the American Medical Association.

Childhood shots have become a $1 billion-a-year endeavor for government since the discovery of polio vaccine 55 years ago. The per-child cost grew more than sevenfold from $155 in 1995 to $900 for boys and $1,200 for girls this year. Costs in the private sector are higher.

Lee and her colleagues surveyed states to find out which shots they provide and to whom. Program managers from 48 states responded. Lee wouldn’t say which states participated because researchers promised anonymity.

Sixteen of the states require health insurers to cover all recommended vaccines.

55 million and their families may be underinsured
About 55 million employees and their dependents get coverage through self-insured companies that are exempt from state mandates. Those people are the most likely to be underinsured for vaccines, said vaccine policy expert Dr. Matthew Davis of the University of Michigan.

According to the research, 17 states reported they were unable to give a vaccine for meningitis to children with inadequate private insurance, even if they were seen in public health clinics. And eight states don’t give pneumococcal shots to underinsured infants and toddlers.

A handful of states don’t provide shots for chickenpox and hepatitis A to the underinsured. Two states don’t provide Tdap, the combined booster shot for tetanus, diphtheria and pertussis (whooping cough) for 11- to 12-year-olds.

More than 1 million insured children are unable to get the meningococcal vaccine leaving them vulnerable to potentially deadly infection, the researchers estimated.

The survey did not ask about two vaccines recommended last year: an oral vaccine for infants against rotavirus, a common cause of childhood diarrhea and vomiting, and a vaccine for girls against human papillomavirus, which can cause cervical cancer.

Workers covered by plans marketed by Aetna and other insurance companies generally are covered for childhood vaccines, although they may have to pay co-payments or satisfy deductibles, said Mohit Ghose, a spokesman for America’s Health Insurance Plans.

Tough decisions
As costs rise, it may be necessary to decide at a national level which vaccines are most important, Davis said. He was not involved in the new study, but wrote an accompanying editorial in the journal.

Officials at the U.S. Centers for Disease Control and Prevention oppose prioritizing vaccines and instead favor better coverage by insurers and more government funding as a safety net, said CDC immunizations director Dr. Lance Rodewald.